All individuals and focus groups agreed that further questioning of a mother who gives an equivocal or a positive response and the sharing of resources and crisis numbers should be done in private. A minority of the experts (advocates from one domestic violence agency and one nonphysician expert) discouraged general screening for domestic violence in front of children older than 2 or 3 years. In fact, although the 2 focus groups with domestic violence advocates both started by supporting private screening, they reached different conclusions. One group reached the consensus that general questions were suitable and perhaps therapeutic for children. The other focus group of domestic violence advocates remained concerned about screening in front of the children. The concerns about screening in front of older children included: the possibility of violence if the child tattles on the mother’s conversation with the physician, and further traumatization of the child by hearing the mother recount the abusive events or by hearing her deny the violence at home, thereby continuing the family secret.
“If the child is aligned with the batterer, the child could go home and say: ’Mom told what you do when you are mad at the doctor’s office today.’”
“The child may understand that Mom is breaking the family secret and be concerned for Mom’s welfare.”
“If the victim lies, and victims often do, the child will hear the mother lie, reinforcing the continued secret.”
Written questionnaires were consistently mentioned by participants as an expedited method for screening in a busy practice. Questionnaires covering developmental and preventive issues are often handed out as part of the well-child visit, and additional questions could be included. By distributing the written questionnaire in advance, victims or potential victims of domestic violence can be identified by their responses; clinic staff can then arrange for follow-up questioning in private. This eliminates the awkwardness of face-to-face questioning followed by escorting the children out of the room if the parent gives a positive response. One participant said, “Questionnaires might help a victim organize her thinking for later discussion.”
The main concerns raised about questionnaires were confidentiality and the impact of concerns about confidentiality on reliability. Also, the questionnaires cannot be used if the violent partner brings the child in for the visit. It was suggested that it would be better if the questionnaires were not part of the medical record.
“If the questionnaire done at the well-child visit becomes part of the permanent chart, the father/perpetrator has access to the chart. This might be dangerous for the victim. Questionnaires could be filled out and then discarded.”
“She might be honest if she knows that it is not being filed in the chart.”
Physician Knowledge and Screening Practices
Only one of the participating physicians was screening for partner violence at the well-child visit. That physician was asking the mother if it was permissible to ask questions about violence in front of her children. At the time, the physician had not experienced any negative effects of this practice and had not considered the specific risk of the child’s telling anyone or of the child hearing the mother’s denial. Another physician was planning protocols for her hospital’s ambulatory clinic to begin screening for intimate partner violence. All of the family physicians screened some adult women but felt that they should screen more consistently. All individuals and focus groups stressed the value of physicians sharing resources and crisis numbers with victims.
The signs and symptoms of the children who witness violence between adults in their home13-22 were not well described by the physicians. These signs and symptoms are important, because recognizing them in the office setting may trigger the physician to screen for violence when universal screening is not being done.
The Links Between Child Abuse and Domestic Violence
Consistent with the literature, nonphysician experts and focus groups thought it was imperative to screen for intimate partner violence when child abuse was suspected and to screen for child abuse when intimate partner violence was identified.9-11 An expert stated, “Looking only at domestic violence or only at child abuse is dealing with just half of the family.”
Only 3 of the 9 physicians had screened for child abuse when intimate partner violence was identified, despite the fact that the pediatricians were more comfortable screening for child abuse than for intimate partner violence.
Participants suggested the following child abuse screening questions when intimate partner violence has been identified: When abuse occurs, are the children hurt? Have you been afraid of your child’s being hurt?